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ND considers allowing outpatient births in hospital facilities

Sara and Lucas Brendel sit with their daughter Emmy, almost 2, Friday, Feb. 10, 2017, in their south Fargo home. Sara wishes she had the option of giving birth in a freestanding birth center. Michael Vosburg / Forum Photo Editor

FARGO—Sara Brendel's first child was delivered in the customary setting, a hospital delivery room. The experience was wonderful, she says. But when it was time to have her second child, she opted for a midwife.

The decision to have a midwife deliver her second child came after she realized it was an option—that, in fact, in many countries a hospital delivery is reserved for high-risk pregnancies.

Both experiences were good ones, but Brendel, a music teacher in Fargo, regrets that she didn't have another option.

"I am not interested in birthing at home, so I have no other choice but the hospital at this time," she said. "I wish I had an 'in between' option of a birthing center."

Minnesota allows freestanding birthing centers attended by midwives, and 11 are licensed across the state. North Dakota does not allow birthing centers—but health officials have proposed offering the option of outpatient delivery services, provided they are in a hospital setting, and staffed with physicians or other licensed medical providers.

The North Dakota State Health Council is scheduled to consider new administrative rules on Feb. 22 to allow the option. It would be available only for routine, low-risk pregnancies.

The impetus for the change was a request from a critical access hospital, which are limited to 25 beds and serve rural areas, to have the flexibility to put the mother and baby in an outpatient room after delivery, said Bridget Weidner, program manager of the state Health Department's division of health facilities.

"It was at the request of the industry," she said. After checking to see how other states regulate outpatient birth centers, a working group for the Health Department came up with draft rules.

"Our work group did discuss freestanding birth centers," Weidner said. "The work group decided the best model for North Dakota was outpatient births as a service of a hospital."

That's because the work group's members, consisting of physicians, including family medicine, pediatrics and obstetrics, and nurses, "felt that very few births were truly low risk and the risks outweighed the benefit to our state," she said.

A study by the Minnesota Department of Health found that "birth centers can be a safe and effective option for low-risk women choosing to give birth in a non-hospital setting." Maternal risk factors include conditions such as diabetes, high blood pressure and infections.

The Minnesota study found that 6.3 percent of mothers and 2.6 percent of infants were transferred from birth centers to hospitals, for reasons including prolonged labor or unforeseen complications. The study authors cautioned that data was limited. The time period covered was 2010 through part of 2013, and only five centers were licensed then.

A national study by the American College of Nurse Midwives, published in 2013, found that of 15,574 women with low-risk pregnancies who planned to give birth at a freestanding center, 84 percent were able to do so; 12 percent were transferred in labor.

The national study found no maternal deaths, and the newborn mortality rate was 0.4 deaths per 1,000 births. More than nine of 10 mothers—94 percent—who delivered at birth centers achieved vaginal births, more than four times the general rate for low-risk women in the U.S.

Minnesota is one of 41 states that allow birth centers open to midwives, according to the American Association of Birth Centers, which accredits birth centers. There are at least 330 birth centers, seen as an option for low-risk women who choose to give birth in a non-hospital setting.

Birth centers outside hospitals provide a lower-cost alternative, the association claims. If 10 percent, or 400,000 of the 4 million women who give birth in the U.S. each year, delivered their babies in birth centers, the savings in facility payments alone would be at least $2.6 billion, the association said, citing figures from government research.

Neither Sanford Health nor Essentia Health in Fargo have immediate plans to offer an outpatient birthing center, if that becomes an option.

"We have many options available for moms to customize their inpatient birth experience, and we are excited to be opening our new birth center in July," said Cyndy Skorick, Sanford's executive director of women's services. "Nationwide there are a few outpatient birth centers in higher-population areas, but this is not a trend we are seeing in this region."

At Essentia, administrators will continue to monitor the progress of the outpatient proposal "and impact it may have in the communities we serve," said Dr. Stefanie Gefroh Ellison, chief of hospital services.

"Most mothers stay in our hospital an average of 24 to 72 hours," she said. The length of stay, she added, depends on the health needs of the mother and baby, monitored by doctors and nurses.

Although no North Dakota hospitals appear to be immediately planning for an outpatient birthing center, state health officials decided to draft rules so they will be in place if needed.

"We decided to be proactive," Weidner said.

Under the draft rule, mothers with low-risk pregnancies and their infants treated in outpatient birthing units would be discharged within 26 hours of birth.

Brendel, who is expecting her second child in May, wishes she had the choice of giving birth in a more home-like outpatient setting. "I think it would be a nice option to have."

Brendel believes she would be more comfortable in an outpatient birth center than at home.

"Not that I expect any complications," she said, "but really, does anybody?"

The inpatient birth center at her hospital is decorated with domestic touches, she said, but still is unmistakably a hospital room, with an institutional feel and filled with medical equipment. Presumably, an outpatient setting, even at a hospital, could be made to feel more home-like, and as a true alternative to an inpatient experience, Brendel said.

"The only location options I really have, though, are either the hospital or at home," she said. "I'll be birthing at the hospital."

Patrick Springer first joined the reporting staff of The Forum in 1985. He can be reached by calling 701-241-5522. Have a comment to share about a story? Letters to the editor should include author’s name, address and phone number. Generally, letters should be no longer than 250 words. All letters are subject to editing. Send to letters@forumcomm.com